1457737967 NPI number — NORTHERN LIBERTIES WELLNESS GROUP

Table of content: (NPI 1457737967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457737967 NPI number — NORTHERN LIBERTIES WELLNESS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN LIBERTIES WELLNESS GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457737967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08650-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-239-3097
Provider Business Mailing Address Fax Number:
215-239-3098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N COLUMBUS BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19123-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-239-3097
Provider Business Practice Location Address Fax Number:
215-239-3098
Provider Enumeration Date:
08/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
LOLAMARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
215-239-3096

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  DC002363 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: OS011923 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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